Recently in Affordable Care Act Category

It used to be that late August in Washington, D.C. was the perfect time to clean the junk out of your office, delete old emails, and go to the dentist. Now, though, the high energy folks in the Obama Administration charged with implementing health reform are bringing yet more change to Washington, D.C..  Yesterday, they sponsored an all-day listening session with stakeholders to gather thoughts and insights on the new Exchanges that are so central to health reform.  They brought together employers, labor leaders, consumer advocates, insurers, and a host of other experts to cover exchange issues such as how to communicate with consumers; small businesses and exchanges; governance issues; promoting delivery system reform; and the role of exchanges in determining eligibility for premium and cost-sharing subsidies and coordinating with Medicaid.

The discussion was incredibly rich, but one theme that emerged over the course of the day - and that also was very much in keeping with HHS's vision for the meeting - is the importance of securing consumer input into health reform implementation and using a transparent decision-making process.  Glen Schor with the Massachusetts' Connector was particularly eloquent on this point, calling transparency a "hallmark" of how Massachusetts has succeeded in implementing health reform.  He and others noted it can be time consuming and cumbersome to solicit consumer input and to share all sorts of details about policymaking, but it is ultimately vital to helping people feel comfortable with major changes.

From a consumer perspective, there also was a fascinating discussion about the kinds of information that people will need to make decisions about their health care coverage under reform.  Of particular note, I thought, were comments by DeAnn Friedholm of Consumers Union about the importance of recognizing that people make decisions in different ways.  Drawing on Consumers Union's experience with publishing Consumer Reports, she pointed out that not everyone is likely to want a detailed chart comparing a health plan along a zillion different dimensions.  Instead, some people may want a much simpler set of information, such as three good health plan options from which they can choose.   While I personally am a huge fan of multi-dimensional charts and love a good spreadsheet, I'm guessing that much of America will want dramatically simplified information about how to secure coverage and enroll in subsidies.

I participated in a panel headed by Director of the Center for Medicaid and State Operations Cindy Mann on coordinating Medicaid and Exchange coverage.  Many of the ideas will be deeply familiar to long-time Medicaid and CHIP experts and advocates, including the need for unified and simplified application and retention procedures for Medicaid and the Exchange; the importance of building a strong information technology infrastructure for eligibility determinations that allows linkages between the Exchanges, Medicaid and CHIP and databases that can be used to verify eligibility; and the value of providing people with multiple ways to apply for (renew) coverage, such as the option to submit applications on-line and/or to secure help from a community-based organization.  At the same time, we discussed that the tax credits for premium assistance and cost-sharing subsidies pose some unprecedented challenges, including that the tax system is based on annualized income and is not designed to respond when incomes fluctuate over the course of a year. 

As intended, the day raised more questions than answers, but, all-in-all, was much better than a trip to the dentist.  Seriously, it was impressive to the extent to which people are beginning to roll up their sleeves and work on turning the health reform law into a practical reality.

Health care "exchanges" are critical to fulfilling the promise of the Affordable Care Act and how states decide to meet their responsibility to establish them will have an enormous impact on children and families.  Today, the Department of Health and Human Services is hosting a stakeholder conference to discuss exchanges. To coincide with the conference, my colleagues, Dawn Horner and Sabrina Corlette, released an issue brief that takes a deeper look at exchanges and what's at stake for children and families. 

HHS's day-long conference is intended to engage stakeholders on the important policy decisions surrounding the establishment and operation of exchanges.  CCF's Jocelyn Guyer will take part in a panel discussion and Dawn Horner will attend the conference. (You can view the conference via be webcast here.)

We'll hear more from them about the conference tomorrow, so let's get back to the issue brief.  "Health Exchanges: New Coverage Options for Children and Families" provides a comprehensive overview of exchanges and key questions policymakers must consider when establishing exchanges.  It outlines the funding and design decisions the states will have to make fairly quickly and points out the broad responsibilities exchanges will have in ensuring that consumers can make informed health care coverage choices.  

For example, the Affordable Care Act requires plans to offer child-only policies (reflecting the importance policymakers placed on the need to ensure that children could secure coverage even if their parents were ineligible for an exchange plan).  Beyond the essential benefits packages, exchange plans must provide children with a comprehensive package of preventive care services (referred to as Bright Futures), including immunizations, well-child visits, vision and hearing tests, health and behavioral assessments, and developmental screenings, with no cost-sharing.  These federal standards are only a floor and states can require plans to cover services for adults and children that are not in the minimum package.  In fact, a number of states already have policies mandating that plans cover specific services, some of them critical to children. (Sixteen states and the District of Columbia mandate that insurers offer at least some level of services for autism.)

Another issue that could impact many families is how well states meet the "no wrong door" policy established by the new law.  It is vital that exchanges coordinate closely with Medicaid and CHIP because many people will move back and forth between subsidized exchange coverage and public program eligibility as their income fluctuates.  The brief points out that states should consider ensuring that some plans offered in the exchange also serve Medicaid and CHIP beneficiaries, creating overlapping provider networks and requiring plans to help facilitate transitions for those in the middle of treatment.

The brief also covers the importance of dynamic technology applications to the success of the exchanges.  The exchange procedures envisioned under the ACA rely heavily on the application of smart technology systems. States should consider setting up a working group now to begin to build these systems. As a first step, a state can pave the way toward electronic interfaces by implementing the proven Medicaid and CHIP automated linkage with the Social Security Administration allowed under CHIPRA to verify citizenship status.

These are but a few of the insights included in the issue brief.  I hope you'll take the time to read it for yourself and share it with others in your state.  We would also love to hear from you on how your state is approaching the establishment of its exchange.

By Patrick Tigue, New England Alliance for Children's Health

While there are many provisions in the Affordable Care Act (ACA) that will benefit children and families, the expansion of dependent coverage to children up to age 26 is among the most important - especially in the short-term. In 2011 alone, as many as 1.64 million previously uninsured young adults are estimated to gain coverage under their parents' health plans. The provision takes effect after September 23, 2010.

Recently, the federal government issued regulations further explaining how this provision will work. Here at the New England Alliance for Children's Health, an initiative of Community Catalyst, we support these regulations because they clarify several important points that will benefit young adults and apply the law with their interests at heart:

• Young adults are eligible for coverage under their parents' plan regardless of what state they live in and whether they are tax dependent, financially independent, or a student, employed, or married.
• Premiums or benefits cannot vary based on the age of a young adult who qualifies as a dependent.
• The provision applies to all health plans and only grandfathered health plans (those in existence prior to March 23, 2010) can exclude young adults with access to an employer-sponsored plan until 2014. After 2014, this exception no longer applies.
• Insurance companies must provide prominent notice to enrollees about the special enrollment period for dependents.
• States have the option to extend dependent coverage beyond age 26.

All of these clarifications and others included in the regulations will ensure that dependent children and their families can take full advantage of this important opportunity to secure the health coverage they need.

While we are enthusiastic about the regulations, we've also been working collaboratively with a group of our partners to offer some suggestions to the federal government on how to improve them in a few key areas:

• Clarify that stepchildren and adopted children are included in the definition of a dependent child.
• Further explain the situations where grandfathered plans can remove young adults who are eligible for employer-sponsored insurance to ensure that this does not unduly burden young adults.
• Require that prominent notice be clear and conspicuous--ideally in the form of a stand-alone document highlighting the availability of the new coverage option and how to enroll.

It's our hope that the regulations will be revised soon to reflect these suggestions, but in the meantime you can find out more about the dependent coverage expansion here. This provision is one of the many examples of the very real opportunities that ACA provides to extend coverage to those who otherwise would go without.

This blog post was originally posted on the Health Policy Hub.  The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.

By Tom Birch, National Child Abuse Coalition

For the first time, with the passage of health care reform in March, federal funding will be available to states to support a range of voluntary home visitation services to pregnant women, young parents and their children, designed to improve maternal and child health, foster healthy child development, and prevent child maltreatment.  Priority for services would go to low-income families living in communities in need of services. 

The new measure authorizes $1.5 billion over five years - with $100 million in 2010 - for the Maternal, Infant, and Early Childhood Home Visiting Program funded by HRSA, in collaboration with the HHS Administration for Children and Families (ACF), through the Title V maternal and child health block grant.  A three-percent share of the funds is reserved for grants to Indian tribes.

Research over the years has produced a strong body of evidence that early childhood home visitation programs are effective in reducing the incidence of child abuse and neglect and in improving child health and development.  While a majority of states already provide early childhood home visitation services to a relatively small number of families, the challenge has been to take this proven effective prevention approach to scale.  The new home visiting program can help to move toward that goal.  

The new funding promises potential for a significant positive impact on children's health care.  Home visiting programs link families to health care resources and focus on healthy outcomes.  Through a strong emphasis on prenatal care, significant costs associated with pre-term births and developmental disabilities are reduced.  Linking families to consistent primary care and immunizations means reduced emergency room costs and reduction in chronic illness. 

Studies have proven the results we hope to see.  Families who received home visiting services were found to be more likely to have health insurance and a medical home, to seek prenatal and well-child care, and to get their children immunized.  Instances of child maltreatment have been lowered significantly.  Babies of parents enrolled prenatally in home visitation services have shown fewer birth complications and higher birth weights.  

On July 21, HHS announced the allocation of $88 million for the first year of funding of the home visiting grants to states, the District of Columbia and each of the five territories.  The allocations are based on the size of the population of children under the age of five living at or below 100% of the federal poverty level in each state. The grant amounts to the states in the first year range in size from $7.78 million to California down to $557,408 to Vermont.

States have completed or are now in the process of conducting statewide assessments to identify existing home visiting programs and areas of high need. States each have immediate access to $500,000 of their allocations for preparing the needs assessments and begin planning their programs.  The remainder of the grant funds will be released in September, after approval of a state's plan for addressing the home visiting needs identified. The law directs states, in conducting a needs assessment, to coordinate with and take into account other needs assessments already ongoing, including those required by the Maternal and Child Health Block Grant, Head Start, and Title II of the Child Abuse Prevention and Treatment Act (CAPTA).

The Administration for Children and Families (ACF) is taking the lead, in partnership with HRSA, in administering grant support for the Tribal Maternal, Infant, and Early Childhood Home Visiting Grant Program.  Applications are being accepted for a total of $3 million in funding available for award in fiscal year 2010.

In applying for the home visitation grants, states must establish quantifiable benchmarks to demonstrate improvements at intervals of three and five years for families participating in the program.  The benchmarks address maternal and newborn health, prevention of child maltreatment, school readiness, reduced crime or domestic violence, family economic self-sufficiency, and coordination with community support services.

The new grant program requires states to allocate at least 75 percent of funding to support home visiting models that are research-based and rigorously evaluated through randomized control trials or quasi-experimental research designs.  The remaining 25 percent of grant funding could go to support promising approaches yet to be evaluated by a similar rigorous process. 

On July 23, HHS published proposed criteria for evidence of effectiveness of home visiting program models to inform the funding decisions for the new program. Comments on the proposed criteria are due by August 17, 2010. 

In future years, the funding for the program would increase from $100 million in 2010 to $250 million in 2011, $350 million in 2012, and $400 million in each of 2013 and 2014 -- HHS plans to allocate the additional funds competitively.  While HHS proposes to give significant weight to the strength of the available evidence of effectiveness of the model or models employed by a state, HRSA and ACF are open to comments on what criteria are appropriate to judge states competitively.  It is anticipated that the criteria for evidence-based models will need to be altered over time as the state of the field changes, so HHS intends to review the evidence base for home visiting models on an ongoing basis to ensure that new evidence is incorporated.  How program models are evaluated and rated will be the key to allocating the competitive funds. 

The views expressed by guest bloggers do not necessarily reflect the views of the Center for Children and Families.

HHS announced today that up to $1 million per state will be available in grants to begin establishing health insurance exchanges. This first round of grants is designed to help cash-strapped states conduct the research and planning necessary to build the new marketplaces. Grant applications are available at: http://www.healthcare.gov/center/grants and are due by September 1, 2010 (there is a pre-application call scheduled for August 5th). Only states are eligible to apply for the grants and no matching funds are required. 

In describing their planning activities in the grant application, states must include information on how they will involve stakeholders in the decision making process, as well as how they plan to build on and integrate the exchange with existing public programs such as Medicaid and CHIP. And in a nod to transparency, states must post information about the planning grants on their websites.  

The administration also released a request for comments on the standards and rules that Exchanges will be required to meet. The administration is encouraging states, consumer advocates, employers, insurers, and other interested stakeholders to provide input. To add your two-cents, go to: http://www.healthcare.gov/center/regulations. Comments are due by October 4, 2010.

By Christine Barber, Community Catalyst

We've all heard the recently-passed Affordable Care Act (ACA) provides a lot of new opportunities for improving health care coverage and access - but we also hear most Americans don't understand what the law actually means for them. At Community Catalyst, we think a major opportunity created by national health reform is improving consumers' access to clear information about their health care options from trusted sources. Consumer assistance programs (CAPs) are a critical way to make this happen.

The ACA included $30 million in grants for 2010 to fund state CAPs and ombudsman offices (Section 1002) to help real people understand their health care options. And the Department of Health and Human Services Office of Consumer Information and Insurance Oversight (OCIIO) just released the grant guidelines for the program late last week. Overall, we at Community Catalyst applaud the guidelines.

A few highlights:

• The grant criteria take steps to ensure that the selected programs are independent. In particular, we are happy to see that the guidelines clearly welcome states to contract with non-profit organizations to provide consumer assistance.
• CAPs must assist people with all types of coverage and provide assistance that is culturally appropriate. In addition, programs must collect data about any problems and questions, which we hope will provide real-time, on-the-ground information about what's working and what's not. Regular feedback to state and local policymakers can help improve health reform implementation.
•  Each state is eligible for one grant award. Therefore, it is important that states know about this grant program, so consumers can get help, no matter their zip code.

Examples like Health Care for All Massachusetts's Helpline, New York's Community Health Advocates, and Health Assist Tennessee have shown us that strong consumer assistance programs can mean the difference between a failed attempt and successful reforms. The Helpline in Massachusetts saw their call volume increase by 400 percent after Massachusetts's health reform law passed. People still call with questions, from enrollment assistance to help with paperwork to navigating the health system.

We hope that states will partner with community-based non-profits wherever possible to help provide consumer assistance. We have seen these models work, and know that they are trusted sources of health care information for communities and for families looking for help in understanding a system that's about to get bigger and more complex.

The CAPs grants are an important step in making sure the public understands and can navigate the health system as it changes. Grant applications are due September 10, and year-long grants will be awarded to states this October.

By Sabrina Corlette, Georgetown Health Policy Institute

In the last couple of weeks there have been reports that some insurance companies have decided they will no longer market "kids-only" policies, in response to the new requirement under the Patient Protection and Affordable Care Act (ACA) that they issue coverage to all children, even those with pre-existing health conditions.  What are these "kids-only" policies, and how many families will be affected if plans drop out of the market?  

Only a small percentage of families buy kids-only commercial coverage - by some estimates these plans constitute 8% of all policies offered on the individual market (in fact, AHIP  found that its surveyed members only cover about 150,000 children through kids-only policies).  In some cases, the parents who buy these policies can't obtain coverage themselves, because it's simply unaffordable or they have health conditions that cause insurance companies to deny their applications.  In other cases, a parent has access to insurance through their job, but it's much cheaper to buy a kids-only plan than to purchase family coverage. 

Currently, companies that sell kids-only policies engage in underwriting, which allows them to deny policies to children who have health conditions.  And if they do issue policies to these children, they often refuse to pay for the very treatment that would help them get better.

The ACA includes an important new reform for families with children that have pre-existing health conditions - as of September 23, 2010, plans are no longer allowed to deny these kids coverage, or to exclude from policies the benefits they need.  This provision is estimated to help 162,000 kids get coverage they otherwise wouldn't have.

This is a reform that should be embraced by everyone - how can anyone justify denying a child access to health care?  And early on, most health insurance companies said they would willingly comply with the new rules.

But lately, that commitment has started to crumble as the companies look at their bottom line and realize that covering kids who need health care will drive up their costs.  In a move that demonstrates how dysfunctional our health system has become - and why the broader insurance reforms, slated to go into effect in 2014, are so vital - many are now saying they want to get out of the kids' market.

What does this mean for families?

First of all, families with children currently enrolled in a kids-only policy don't need to panic.  Under another federal law - the Health Insurance Portability and Accountability Act (HIPAA) - these policies are "guaranteed renewable," which means that they can keep their children enrolled in the policy if they wish.  Most plans won't completely exit the market - they are simply no longer selling the policy to new customers.  Families should be aware, though, that they could face higher premiums over time.

For families whose kids don't currently have coverage, they may find that fewer plans are offering kids-only policies.  But that doesn't mean they won't be able to access coverage. Many families will want to explore whether their child is eligible for Medicaid or CHIP, both government-sponsored programs for low- and moderate-income families available in every state. Most uninsured children in the country - two out of three - are eligible for these programs, which offer affordable coverage without imposing any pre-existing condition exclusions.

If parents are looking for insurance on the individual market, they should check out the new HHS website, www.healthcare.gov.  The site has easy-to-use comparative information on health plans' family coverage options in every zip code. And under the ACA, even if their child has a pre-existing health condition, plans will no longer be able to deny them coverage or limit benefits, although it is possible that they could charge them more if their child has such a condition.

Based on regulations released by the Administration earlier this week, families shopping for plans may also face "open enrollment" periods. (See Administration's fact sheet addressing "open enrollments.)  Insurers want to curb the practice of people signing up for coverage only when they become sick.  But the effect could result in children having greater difficulties obtaining coverage when they most need it. Federal officials need to ensure that "open enrollment" policies include strong protections for kids, including making sure that children cannot be improperly dropped from coverage and that a child can bypass the enrollment period at critical junctures, such as when a child loses employer, Medicaid/CHIP or other coverage.

The website also has information on the new high risk pools, which are established in every state to provide affordable coverage to people who've been uninsured because of a pre-existing health condition.  For some families, if they can show their child was either denied coverage or charged an excessive amount for a policy, and has been uninsured for at least 6 months, these new high risk pools could be a viable option.  Federal officials could also revisit the pools' eligibility requirements to ensure that sick children facing a loss of coverage can access care without having to wait 6 months. Additionally, state and federal officials running the pools need make sure the application and enrollment process for these kids is simple and accessible, and that the benefits effectively meet children's unique health care needs.

Over the coming weeks and months, it will be critical for state and federal officials, as well as advocates for children and families, to closely monitor health insurance companies and cry "foul" against any business decisions that could negatively impact kids.

Of course, in 2014, when the full range of health insurance reforms are implemented, many more options will become available.  And the dysfunctional insurance industry model that denies millions of families access to coverage when they need it the most will hopefully be a thing of the past.

For more information, see answers to some frequently asked questions, available here. 

Last week, the National Association of Insurance Commissioners held a first of many planned meetings on health care reform.  In many ways, state insurance commissioners, have become the front lines of health reform implementation as they are responsible for ensuring that health plans are compliant with the insurance reforms in the Affordable Care Act and they will play a key role in the establishment of the exchanges.

For this meeting, at the top of the agenda was the exchanges and the discussion ran the gamut, from basic questions about exchange responsibilities to detailed analysis of how to limit adverse selection. The consumer perspective was well represented with our colleague at the Georgetown Health Policy Institute, Sabrina Corlette, who testified along with Tim Jost of Washington and Lee University. Tim shared his view that the success of an exchange will depend greatly on its ability to establish a streamlined enrollment and eligibility system that is seamlessly linked to Medicaid and CHIP.

Interestingly, the issue of coordination between the exchanges and Medicaid and CHIP brought forth many questions from the represented commissioners. More than once we heard reference to the fact that public programs, and the populations they serve, are a new world for insurance commissioners and that they are eager for more information. Key issues on their minds were how to maintain continuity of care between those moving back and forth between exchange and Medicaid/CHIP coverage, what IT funding and/or technical assistance will be available to assist Medicaid/CHIP agencies, and how to align the more "prescriptive" eligibility rules of Medicaid/CHIP with the tax credits so that enrollment in exchanges is consumer friendly.

The conversation was a good start - but also a good opening for ongoing dialogue with and education to state insurance commissioners on the central role that exchanges will play in helping people to secure subsidies for coverage and in facilitating their enrollment into Medicaid and CHIP. Georgetown CCF submitted comments to the NAIC on these critical issues.

For the meeting agenda and other materials, visit the NAIC site. 

By Eugene Lewit and Liane Wong

The David and Lucile Packard Foundation

The percent of uninsured children has consistently declined, despite deterioration of coverage for adults and the economy. This is one of the significant but frequently overlooked good news stories of recent years.

The gains in children's coverage have been due in large part to actions taken by states to simplify enrollment and retention processes for their Medicaid and CHIP programs while expanding eligibility for those programs. In many states, policy advocacy groups have played important roles in spurring and supporting progress in their states. These organizations are likely to continue to be important players in the implementation of CHIPRA and broader health care reform. Yet, there has been little rigorous, systematic research on how advocacy groups do their work and the strategies they employ to achieve their objectives.

Two recently released issue briefs based on findings from an on-going evaluation of the David and Lucile Packard Foundation's Insuring America's Children: States Leading the Way (IAC) grantmaking strategy attempt to fill some of this knowledge void. The briefs examine some of the state-based advocacy work supported through IAC and identify the lessons that have been learned regarding how to effectively support and promote growth of children's health coverage.

In the first brief, State-Based Advocacy as a Tool for Expanding Children's Coverage: Lessons from Site Visits to Six IAC Grantee States. Evaluation Brief 1, the authors summarize key findings gleaned from in-depth site visits to states where IAC has made its most substantial investment in advocacy through multiyear "Finish Line" grants. These findings describe how persistence, flexibility, creativity and commitment to conducting effective states-based advocacy, especially in a changing environment, can benefit coverage expansion to all children. They also describe the importance of building strong and broad-based coalitions that include both grassroots and state-level stakeholders, an often key step toward maintaining a unified voice among a sometimes crowded community of advocates working to improve children's well being. While acknowledging that much work remains, the brief pinpoints a number of important gains in children's coverage since the IAC efforts began -- gains that have resulted despite a severe and ongoing economic downturn.

The second brief, Strategic Engagement of Policymakers is Key to Advancing a Children's Health Care Policy Agenda. Evaluation Brief 2, examines the benefit that positive engagement of policymakers can have for advocates to move the children's health care coverage agenda forward in states, as well as the strategies for making this engagement happen. Understanding states' unique political environments is one important first step toward this engagement. Further strategies include identifying, nurturing, and supporting political champions; creating strategic links between grassroots organizations and policy advocacy groups; creating effective, appealing messages for policymakers; establishing advocacy groups as the "go-to" resource for reliable data and information; and sharing ownership of agendas and successes with champions and key policymakers.

These briefs provide objective validation of the advocacy strategies and tactical innovations employed by veteran advocates throughout the country. They also offer practical and field-tested ideas for advocates looking for new ways to accelerate the pace of change. Most importantly, they remind us that tough, smart advocates can guide and support leaders in continuing the children's coverage success story.